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3Review: Blood PressureBlood pressure is the amount of force (pressure) applied to the artery walls.Systolic: The force applied to arterial walls during ventricular systole.Diastolic: The force applied to arterial walls during ventricular diastole.

4HypertensionChronic hypertension aggravates atherosclerosis and increases vascular resistance (vasoconstriction) within the brain.Positive effects: Increased vascular resistance protects the brain from the damaging effects of systemic hypertension.Negative effects: Predisposes the brain to cerebral ischemia by impairing vasodilator responsiveness. When diastolic BP exceeds 120mmHg, the ischemic brain is at high risk of hemorrhage.

5Acute on Chronic HypertensionAcute increases in blood pressure superimposed on a chronic hypertensive state.Approximately 50% of all patients positive for an acute ischemic stroke will have a history of preexisting hypertension.On average these individuals will have higher blood pressures post acute stroke than those who were previously normotensive.

6Blood Pressure ManagementTreatment of hypertension should be done very cautiously.Neurological deterioration has been associated with precipitous decreases in blood pressure induced by emergency antihypertensive treatment.When blood pressure drops below the lower limit of cerebral blood flow auto-regulation it causes more widespread cerebral hypoperfusion.

9Utilized in Ischemic and Hemorrhagic Stroke Standing OrdersLabetalol (Trandate)Potent alpha and beta blockerSlows heart rate and decreases peripheral vascular resistanceUse cautiously in patients with constrictive airway diseasesIVP: Given over 1-2 minutes in 10mg increments, can be repeated every minutes (max dose 300mg)Drip: Give a 10mg bolus, followed by a drip started at 2-8mg/minCan be administered in ICU/CCU, ED, PACU, AMB Surgery, Radiology, CardiologyUtilized in Ischemic and Hemorrhagic Stroke Standing Orders

10Nicardipine (Cardene)Calcium channel blockerDecreases systemic vascular resistance and blood pressureAdministered as an IV infusion, started at 5mg/hour and may be increased by 2.5mg/hour every 15 minutes (max 15mg/hour)Contraindicated for patient’s with conduction deficits (i.e. Second/Third degree heart blocks)Can be administered in ICU/CCU and EDUtilized in Ischemic and Hemorrhagic Stroke Standing Orders

11Nitroprusside (Nipride)Potent vasodilator used in emergent hypertensive conditionsActs directly on venous and arterial smooth muscleAdminister as an IV drip beginning at 0.3mcg/kg/min, titrate by 0.2mcg/kg/min to desired MAP (max 10mcg/kg/min)Monitor closely for cyanide toxicityCan be administered in ICU/CCU and EDUtilized in the Hemorrhagic Stroke Standing Orders, recommended for consideration in Ischemic Strokes.

12Cyanide ToxicitySigns and Symptoms: Nausea, vomiting, diaphoresis, apprehension, headache, restlessness, muscle twitching, dizziness, palpitations, retrosternal pain and/or abdominal pain.If this occurs, stop the infusion and symptoms should resolve within 10 minutes, if not then effects are from another source.

13Utilized in the Hemorrhagic Stroke Standing Orders.Enalapril (Vasotec)An ACE-inhibitor that prevents the conversion angiotensin I to II, preventing vasoconstrictionDecreases peripheral arterial and venous resistanceAdministered IVP at mg every 6 hours as neededContraindicated in patients with hypersensitivity or allergy to ACE-inhibitorsCan be administered in ICU/CCU, ED, PACU, 2CN, AMB Surgery, Radiology, CardiologyUtilized in the Hemorrhagic Stroke Standing Orders.

16Post-Hemorrhagic StrokePatients are at an increased risk for cerebral vasospasm after spontaneous subarachnoid hemorrhageMedically induced hypertension has proven to reduce vasospasm post bleedMethods:Intra-vascular volume expansion: Used to stabilize vessel walls from spasm/collapseVasopressor support: Vessels are less likely to spasm while acutely constrictedAdministration of anti-diuretics: Assist in the retention of fluids to stabilize vessel walls

17Cerebral IschemiaUtilization of intra-vascular volume expansion and induced hypertension are effective in reversing ischemic deficits from vasospasm, provided that the treatment commences before the cerebral infarction occurs. If not, ultimately it can be used to prevent further ischemic damage to the cerebrum post infarct.